Don’t shoot the messenger: What depression can teach us about how we live our lives

DSM/ICD and the Medicalisation of Depression

Jacquie Keelan

The ICD10 defines a mild Depressive Episode as follows: “Depressed mood, loss of interest and enjoyment, and reduced energy leading to increased fatigability and diminished activity.” DSM5 says of Depressive Disorders: “The common feature… is the presence of sad, empty, or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual’s capacity to function.” It covers seven categories of disorders, with subcategories based on severity, presumed etiology, descriptive evidence, duration and the presence of any psychotic features, and there is further sub-categorisation based on internalising or externalising factors.

Depression is a highly medicalised disorder, it seems, on the increase and with widespread implications economically and socially. The World Health Organisation and the World Economic Forum both say that mental illness represents the biggest economic burden of any health issue in the world, costing $2.5 trillion in 2010 and projected to cost $6 trillion by 2030. Worldwide, 350 million people suffer from mental health conditions.

WHO assesses depression as the leading cause of disability in the world, with 1 suicide every 40 seconds, over 800,00 a year. For every person who completes a suicide, another 20 may attempt it. Up to 10% of GP visits in the UK concern depression and 1 in 6 people in the UK will experience depression in their lifetime, with a 50:50 chance of recurrence.

With definitions and statistics such as these, it’s little wonder depression is described as an epidemic. But perhaps the real question these statistics beg is that if this “sad, empty, irritable” mood is so common, why do we label it a disorder and pathologise it? I’m not suggesting that the ICD10 or DSM5 descriptions of what they call depressive disorders are wrong, but that their diagnosis of what constitutes a disorder is – something experienced by 1/6th of the UK population is hardly outside of normal mental function.

Sense and Existence
From an existential perspective it seems rather a natural and understandable reaction to finding ourselves thrown into life with no control over our context or facticity, prone to the vicissitudes of a world that is at best indifferent and at worst cruel and unjust. Existential thinkers have an acceptance of suffering as an inescapable part of life, and their standpoint might in turn help us rethink our view of (non-psychotic) depression.

When Sartre says “existence precedes essence” (Sartre, 1946:3), I understand him to mean the same as Nietzsche saying “God is dead” (Nietzsche, 1961:14). That is, there is no pre-existing, fixed structure of meaning laid down by God that we are born into and in which we find our stable place. There is nothing to alleviate our responsibility and absolve us from the time-consuming, difficult and painful business of meaning-making. If God is dead, the burden rests with us alone.

We discover suffering as newborns, when there is pain, want and unmet needs, and life continues to throw up examples as we age. Good does not always prevail, justice is not always done, humans are not always humane and we may well not be rewarded in any afterlife. So questions arise and doubts surface and we are continually confronted with the unsettling arbitrariness of our existence. No wonder we feel uneasy, anxious, tangential. We are right to.

As Tillich puts it, “The anxiety of meaninglessness is anxiety about the loss of an ultimate concern, of a meaning which gives meaning to all meanings. This anxiety is aroused by the loss of a spiritual centre, of an answer, however symbolic and indirect, to the question of the meaning of existence.” (Tillich, 1952:47)

To make sense of ourselves and our actions and to find purpose, value and joy in life we must therefore make our own meaning, because a life without meaning is intolerable. And there is no narrative arc to this. We never ‘get there’ but are continually engaged in the process as our circumstances, relationships and knowledge evolves.

Life Stories and Life’s Meaninglessness
The freedom to create our own lifestory can be seen as a gift, but freedom also entails uncertainty. It requires courage to accept the responsibility of our choices, hence we attempt to deny or evade it by replacing it with false gods – power, money, status, sex, alcohol, adventure, religion, causes, conformity. When these fail to work adequately, emptiness may return. This is the story of our lives – ongoing confrontation with the essential meaninglessness of life, which we cannot change but can only live with in productive tension, acknowledging that the meaning we are creating is necessarily contingent but still has value if chosen truthfully, consciously and in authenticity.

Rollo May challenges the idea that it’s good or even possible to live without anxiety, “We are more apt to feel depressed by the perpetually smiling individual than the one who is honestly sad. If we admit our depression openly and freely, those around us get from it an experience of freedom rather than the depression itself.” (May, 1973: ) Victor Frankl concurs: “Existential frustration is in itself neither pathological nor pathogenic. A man’s concern, even his despair, over the worthwhileness of his life is an existential distress but by no means a mental disease.” (Frankl, 1956:Loc 1328)

Instead, we may choose to see these feelings as a natural and potentially fruitful reaction to life, a prompt to asking ourselves the most important question of all – What is the meaning in life?

It seems apt that two key demographics of depression ‘sufferers’ are 16-19-year-olds (where suicide is the second leading cause of death), who are questioning the world and perhaps discovering the values they inherited do not fit them, and the over-65s, who may be looking back and reflecting on a life lived less well than it might have been and with less of any life ahead of them.

Existence and non-existence
Time, and its passing, is crucial in our understanding of our flimsy place in the world. Our existence is always undermined (or underlined?) by non-existence. As Schopenhauer says, “The vanity of existence is revealed in the whole form existence assumes: in the infiniteness of time and space contrasted with the finiteness of the individual in both; in the fleeting present as the sole form in which actuality exists; in the contingency and relativity of all things; in continual becoming without being; in continual desire without satisfaction.” He advocated (if not practised) withdrawal from the world, informed by Eastern philosophies like Buddhism where craving is the cause of all suffering. For Schopenhauer, we are doomed to ricochet between the torment of unfulfilled desire and the tedium of fulfilled desire.

This connection between desire and dissatisfaction seems to me fundamental to our understanding of depression as a modern, first world, epidemic although anthropology, art and philosophy reveal that emotional pain has always been universal. Possibly we hear about it more now because in the West we are less preoccupied with the basic requirements of sustaining life and because fewer of us are turning to organised religion to fill the meaning-shaped hole in our lives.

Western conceptualisation
Lacan is interesting on the subject when he says desire is what drives us but is necessarily destined to remain unfulfilled. Because it is defined as what is missing, when one desire is fulfilled, another must take its place. For Lacan, “Desire begins to take shape in the margin in which demand becomes separated from need.” That is, when our needs are largely met, our demands are for our desires – desire causes suffering but is also a form of luxury. In the West, the margin between demand and need is huge for many.

Westerners are most likely to conceptualise emotional distress as inner, private and dispositional. There are a number of theories to explain the differences (somatisation hypothesis, disease theory, stigmatisation theory, acculturation) but one intriguing finding from my research was that middle-class Westerners are significantly more likely to seek treatment for depression than any other ethnic or cultural group (Karasz, A; Garcia, N; Ferri, L, 2009)

Depression is seen as a legitimate ‘mental illness’ – unrelated to social, situational or interpersonal problems – that is most appropriately treated professionally. Since when did we stop being the experts on ourselves?

I’ve worked with end-of-life clients in a hospice and I’ve been struck by the number who list their conventional achievements and possessions and insist repeatedly, “I’ve had a good life, haven’t I?” as if I knew the answer. It seems to be the clients who’ve had a bumpier ride through life who can accept the end more easily, and I think this is related to learning to value its preciousness at an earlier stage.

This Western propensity to medicalise depression suggests that the social norms we’ve created around ourselves are themselves pathological. Intensifying market capitalism creates a world that serves the wants of the very few extremely well, with intense pressure on the rest to conform to ensure political stability. Dissatisfaction feels unsafe because sticking one’s head above the parapet makes one vulnerable to being shot down.

Laing and irrationality
R D Laing believed that we constructed, collectively, a form of social insanity and he talked about the mismatch between truth and social reality. “Our capacity to think, except in the service of what we are dangerously deluded in supposing is our self-interest and in conformity with common sense, is pitifully limited… an intensive discipline of unlearning is necessary for anyone before one can begin to experience the world afresh, with innocence, truth and love.” (Laing, 1990:21) Depression may be a rational response to an irrational world, but we can unlearn and relearn.

Lived experience
I recognise the earlier descriptions of depression very well. Ten years ago I had three children, a job I loved, a new home, a lovely husband. Sounds good? Felt awful. The children were all under 4, the job was demanding, the house was a run-down money pit, the husband I only saw on relay-sleep handovers. I felt unsettled in myself, disappointed in everyone else, worried, angry, guilty and exhausted. My GP diagnosed post-natal depression and prescribed anti-depressants.

My hormones, neuro-transmitters or genes may have played a part, but really, I knew what it was – there was no space in life to do the things that brought me peace and pleasure, and I had put myself in this position. At that stage, my responsibilities overwhelmed my freedom and sometimes that is the case. Sometimes in life we have to put our heads down and get on with it as best we can, for what we have chosen to believe is the greater good or because we really do not have a choice over our circumstances.

It’s humbling to quote Victor Frankl after my own tiny story but he has such wisdom to impart that I’ll swallow it. “Everything can be taken from a man but one thing: the last of the human freedoms – to choose one’s attitude in any given set of circumstances, to choose one’s own way.” (Frankl, 1963:Loc 913) His logotherapy supposes man is driven by a will to meaning in one of three ways, including “the attitude we take to suffering” and he quotes Nietzsche: “He who has a why to live for can bear with almost any how.” (Frankl, 1963:Loc 1045)

It’s a philosophy that can support us when we’re feeling sad, empty and irritable – or worse – because it returns to us our freedom and our power. Equally sustaining is the knowledge that this too will pass. We are creatures trapped in temporality, so nothing lasts and everything changes. As Emmy Van Deurzen says, “When we are depressed we should know that we can expect to find hope and joy again.” (Van Deurzen, 2010:307)

Pharmaceuticals
I cashed my GP’s prescription but didn’t take the pills, although it would be unethical as practitioners to dismiss pharmaceuticals outright. If a timely course of anti-depressants prevents harm or even suicide, then it’s entirely appropriate – at least until sufficient equilibrium is attained to address underlying questions. Lithium, rTMS, ketamine, TCAs, SSRIs – they’re all quick, easy and relatively hassle-free but perhaps they’re also an anaesthetic rather than an answer. With drugs, there’s no need to spend hours on the couch looking honestly at oneself (never a pretty sight), but Szasz reminds us not to “mistake medicine for magic”.

Interestingly, the reign of anti-depressants is declining, with worldwide sales predicted to drop from $15bn in 2003 to less than half by 2019 as placebos prove to be almost as effective. The Royal College of Psychiatry suggests 4 out of 5 depressed people will improve without any intervention within 4-6 months (op.cit).

The role of depression
Either way, the prevailing bio-psychiatric view of depression shouldn’t preclude us from widening out the issue because a simplistic view helps no one, least of all the depressed. The beauty and joy we feel in life can only exist in comparison with the loneliness and the sorrow; if every experience carried the same emotional value and moral weight, we couldn’t distinguish between them. Depression can be a wake-up call that reminds us that there is something important that is not being expressed or realised in our lives. Why would you want to shoot the messenger that brings you such important news?

Jacquie Keelan is a student on the DProf in Existential Psychotherapy & Counselling at NSPC, London. She has a Diploma in Person-Centred Counselling. She is a volunteer counsellor at a hospice and has a particular interest in loss, end-of-life issues and birth trauma.